TRUST
If trust exists between employees and
senior management, introducing
safety standards and norms to the
organization is less difficult. In a
trusting environment, employees feel
supported when they report safety
concerns and believe that doing so is
part of their responsibility and
contributes to improving patient care.
They are confident that such reports
are thoroughly analyzed, that
appropriate actions are taken, and
that feedback is provided to both the
involved employees and the
organization (Helmreich and Merritt
1998).
An organization will have a harder
time with initiating a culture change
if it is moving from a punitive culture
in which errors were not reported or
discussed for fear of retribution. Such
a transformation requires longer-term
work that involves ongoing dialog
with physicians and employees. It
also demands that senior leaders
demonstrate their commitment to the
values of a just safety culture and a
learning organization.
Trust is the hardest value to earn
and the easiest to lose. Trust cannot
be banked. One untrustworthy act
may destroy an individual’s
reputation as well as the fragile
40 | LEADING A PATIENT- SAFE ORGANIZATION
SIDEBAR K
Cultural Change at the Veterans Administration (VA)
Patient care in the VA environment was frequently criticized for being
below standards. In the late 1990s, Ken Kizer, then the Under Secretary
for Health for the U.S. Department of Veterans Affairs, made a
commitment to decrease the error rate at VA facilities.
First, the errors were audited and reported. This revealed some 3,000
errors over 18 months that resulted in 700 patient deaths. Second, a
patient-safety improvement initiative was undertaken. This involved
implementing changes in administrative procedures, contracting and
purchasing, technology, and nursing care and medical practice. Other
initiatives by the VA included establishing systemwide bar coding,
eliminating hazardous medications from patient care areas, reducing use
of restraints, and substituting the fault-finding hierarchy of medicine with
greater institutional trust and more personal responsibility.
VA policies now stress organizational and interpersonal cooperation in
the investigation of errors rather than individual punishment. It has also
monetarily recognized employees who contribute to the safety initiative by
suggesting improvements. In late 1999, the VA required that all
permanent employees complete 30 hours of continuing education each
year, of which a third must focus on patient safety and quality. The VA has
also increased the use of simulators for medical procedures.
The key to the achievement of such major patient advances was once
again the leader. Ken Kizer (who is now head of the National Quality
Forum) had a vision and laid out the path for the VA to follow (Luciano
2000).
structure of a developing safety
culture.
ORGANIZATIONAL
ASSESSMENT
A baseline assessment of the
attitudes about safety of physicians,
employees, executives, and board
members is instructive. Such a
survey can ask the following: